Cyberbullying and mental distress among adolescents in secondary school: Tunisian cross sectional study

Cyberbullying and mental distress among adolescents in secondary school: Tunisian cross sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cyberbullying and mental distress among adolescents in secondary school: Tunisian cross sectional study Donia Ben Touhemi, Chaabane Maryam, Khemakhem Khaoula, Chiha khadija, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4148550/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Ours study aimed to describe the characteristics of adolescents who are victims of cyberbullying and to evaluate the psychological state of these victims. Methods: This is a cross-sectional, descriptive, and analytical study conducted with a representative sample of adolescents attending 6 schools in the Sfax region during the month of February 2022. The pre-established form containing socio-demographic and family information was used. Cyberbullying was assessed using the "Cyber-Harassment Student Survey". Mental distress was evaluated using the Depression Anxiety Stress Scales (DASS-21), validated in Arabic. Results : Data was collected data from 396 adolescents, of which 54.8% were female. The average age of participants was 16.65 years. Cyberbullying was reported by 47% of the surveyed adolescents. Factors associated with cyberbullying in these adolescents included residing in urban areas (p = 0.017), experiencing relational problems with parents (p = 0.001) and siblings (p = 0.002), the presence of behavioral problems in school (p = 0.009), and low academic performance (p = 0.000) Among cyberbullying victims, 41.3% reported moderate to severe depressive symptoms; 47.8% had moderate to severe anxiety levels, and 29.5% had moderate to severe stress levels. Cyberbullying was strongly correlated with depression (p < 0.0001), anxiety (p = 0.00), and stress (p = 0.00). Conclusion: The results of this study indicate that cyberbullying is widespread within schools and has negative consequences on the mental health of young individuals. Recognizing this prevalence is essential and calls for a prevention strategy against cyber-related issues. adolescents cyberbullying Mental distress depression anxiety Figures Figure 1 Introduction Young people are now closely connected to social networks and their smartphones. This fusion with technology has given rise to the concept of 'virtualescence' (Gozlan) ( 1 ), which describes adolescence in the digital age., where online spaces are used to address the psychological challenges of adolescence ( 2 ). Social media stands out for its ability to instantly share online content with thousands of people within seconds, thereby reducing distances and privacy boundaries. As a result, adolescents are increasingly involved in interactions related to cyberbullying (CB): a new form of harassment through electronic media. CB encompasses acts of intimidating, threatening, or coercing individuals online through social media, emails, text messages, blog posts, or any other digital or electronic communication method. This category of harassment has become a global phenomenon, affecting both adolescents and children. It is rapidly expanding independently of the country development level, with a prevalence ranging from 6–46%." It is important to note that despite the terms 'virtual' and 'cyber,' this violence has real consequences, affecting individuals with concrete emotions and social connections ( 3 ). Its psychological consequences appear to be stronger and more enduring than traditional bullying. It can cause severe psychological disorders such as depression, withdrawal/isolation, loss of self-esteem, and even suicidal thoughts and suicide attempts. In Tunisia, few studies have been conducted to assess the prevalence of cyberbullying among adolescents. A study by Bassem Abida in 2019 ( 4 ) at Sfax, Tunisia revealed a rate of 34.4%, and another study in 2018 ( 5 ) in Sousse found a prevalence of 22.2% among 1111 middle school students. This urgency is further underscored by a study involving samples of adolescents from both Tunisia and Lebanon, which has highlighted a significant connection between cyberbullying and mental distress. ( 6 ) It is in this context that we conducted our study, which aimed to: Identify the individual and environmental characteristics of adolescents victims of cyberbullying Assess the psychological state of cyberbullying victims Methodology This study was conducted during the month of February 2022. It took place in public secondary educational institutions in the Sfax region, Tunisia. A cross-sectional, descriptive, and analytical method was undertaken. 1. Study population : The target population consisted of students enrolled in public secondary educational institutions. 2. Study Procedures Prior to the survey, we obtained the approval of the regional education authorities “Sfax 1” and “Sfax 2”. Subsequently, we randomly selected 3 secondary educational institutions under each of these authorities. Within each institution, we also randomly selected classes representing various grade levels. The adolescents answered the questionnaire in a self-administered manner, following informed consent. Two child and adolescent psychiatrists were present during this stage to emphasize the anonymous nature of the survey and, if necessary, to clarify or comment on the questions. 3. Population All adolescents enrolled in secondary education institutions in the Sfax region, Tunisia, were eligible for our study. The only exclusion criteria were refusal to participate in the study or documented psychiatric history. 4. Data Collection 4.1 Information Sheet: The questionnaire was organized into several sections: sociodemographic characteristics, family environment, education, and leisure activities of adolescents. 4.2 Psychometric Tools 4..3.1 Cyber-Harassement Student Survey : Beran and Li's 15-item Cyber-Harassment Student Survey was employed to evaluate cyberbullying (7). The survey included questions that focused on the frequency of students' exposure to, personal experiences with, and involvement in cyberbullying. Each question was treated independently, and responses were subjected to descriptive analysis. Participants rated their responses on a Likert scale, ranging from "never" to "almost every day," with higher scores indicating a higher level of cyberbullying experience. Since these scales were not initially available in Arabic during the study, we utilized a version translated into Arabic by the authors, which was subsequently reviewed and corrected by an Arabic teacher. 4.2.1 Stress Depression, Anxiety, Stress Scale (DASS21) : This scale, developed by Lovibond et al., 1995 (8), assesses three negative emotional states (Depression, Anxiety, and Stress). The depression scale assesses dysphoria, hopelessness, lack of interest/engagement, devaluation of life, self-deprecation, anhedonia, and inertia. The anxiety scale assesses autonomic arousal, situational anxiety, skeletal muscle effects, and experiences of anxiety. The stress scale assesses difficulty in relaxing, nervous arousal, and mood changes (distress, restlessness, irritability, hyperactivity, and impatience). These items were rated on a 4-point Likert scale, ranging from 1 (did not apply to me at all) to 3 (applied to me very much or most of the time). Total scores for depression, anxiety, and stress were calculated by aggregating their respective points. Each total was then doubled and categorized as 'normal,' 'mild,' 'moderate,' 'severe,' or 'extremely severe.' The validated Arabic version (9) was used in our study." 5. Statistical analysis: The data entry and analysis were performed using the Statistical Package for Social Sciences (SPSS) software in its 26th version. The statistical study consisted of two parts: 5.1 Descriptive Study: Quantitative variables were described using means (M), medians, standard deviation (SD), and extreme values. For these variables, we checked the normality of the distribution using the Kolmogorov-Smirnov test and the Shapiro-Wilk test. Qualitative variables were described using absolute frequencies and relative frequencies (percentages). 5.2 Analytical Study: For the analytical study, We used: The chi-square test (χ2) to compare two qualitative variables or Fisher's exact test when one or more of the theoretical cell frequencies in the contingency table are less than five. Independent samples t-test to compare means when dealing with one dependent quantitative variable and another independent qualitative variable. Results 1. Response Rate: Six hundred questionnaire samples were distributed across six schools, and 396 forms were collected. The response rate was 66%. 2. Characteristics of Participants: The average age of recruited adolescents was 16.69 years, with a predominance of females, and more than half were enrolled in the first year of secondary school. The main descriptive results of the sample are presented in Table I. Table I: Descriptive characteristics of recruited adolescents. Data Results Mean age 16.69 years Sex ratio 0,827 N(%) School level 1st year 114(51,8) 2nd year 89(40,5) 3rd year 13(5,9) 4th year 4(1,8) 3. Cyberbullying in schools: In our study, 185 (46.7%) of the participants reported being victims of cyberbullying, and 29.7% of adolescents reported witnessing an act of cyberbullying. Among the cyber victims, 9.1%, in turn, used new technologies to aggress their peers, thus becoming cyber aggressors. Among the victimized adolescents, 58.4% (n = 108) were attacked online once or twice. (Table II). Table II: Prevalence and characteristics of cyberbullying: (N= 396) N(%) Victims of cyberbullying 185 (46,7) Witnesses of cyberbullying 117 (29,7) Cyber aggressor 36 (9,1) Frequency of cyberbullying among victims (N = 185) Once or twice 108 (58,4) Sometimes 61 (33) Several times 14 (7,6) Every day 2 (1,1) 4. Individual and environmental characteristics of adolescent victims of cyberbullying: The individual and environmental characteristics of adolescent victims of cyberbullying are presented in Table III. Table III: Individual, family and school/social factors associated with Cyberbullying. Factor Cyberbullying p Victims Non-victims Socio-demographic factors : Age 17 IQR [16 - 17] 17 IQR [16 - 17] Gender Female 106(57,3) 110(52,8) 0,38 Male 79(42,7) 98(47,1) Personal history Medical Surgical Yes 5(2,7) 4(98) 0,74 No 180(97,3) 204(2) Personal psychiatric history Yes - - - No 185(100) 208(100) Geographic origin urban 167(90,3) 200(96,2) 0,017 rural 18(9,7) 8(3,8) Level Socio-economic low 62(33,5) 74(35,6) 0,66 Medium to high 123(66,5) 134(64,4) Family environment factors Father's education Primary 33(17,8) 25(12) 0,105 Secondary/ university 152(82,2) 183(88) Father's activity inactive 5(2,7) 2(1) 0,261 active 180(97,3) 206(99) Mother's education Primary 31(16,8) 29(14) 0,439 Secondary/ university 154(83,2) 179(86) Activité de mère Inactive 90(48,6) 98(47,1) 0,761 active 95(51,4) 110(52,9) Family medical and surgical history Yes 14(7,6) 10(4,8) 0,254 No 171(92,4) 198(95,2) Family psychiatric history Yes 5(2,7) 2(1) 0,261 No 180(97,3) 206(99) Parents' marital status United 168(90,8) 194(93,3) 0,367 Separated 17(9,2) 14(6,7) Parents' marital conflicts Yes 21(11,4) 17(8,2) 0,287 No 164(88,6) 191(91,8) Relationship problems with parents No 165(89,2) 204(98,07) 0,001 Yes Physical 2(1,1) 3(1,4) Verbal 8(4,3) 0 Neglect 5(2,5) 1(0,53) Lack of communication 5(2,5) 0 Relationship problems with siblings No 164(88,6) 203(97,6) 0,002 Yes Physical 2(1,1) 1(0,4) Verbal 9(4,9) 2(1) Rivality 5(2,7) 2(1) Lack of communication 5(2,7) 0 School-related factors School results Good 35(18,9) 63(30,3) 0,009 Poor to average 150(81,1) 145(69,7) Academic repetition Yes 46(24,9) 38(18,2) 0,111 No 139(75,1) 170(81,8) School-related problems No 158(85,4) 200(96,1) 0,000 Yes 11(5,9) 11(5,9) 2(1) 4(2,2) 4(2,2) 3(1,4) 4(2,2) 4(2,2) 0 8(4,3) 8(4,3) 3(1,5) Relationship problems with peers Yes 10(5,4) 6(2,9) 0,207 No 175(94,6) 202(97,1) Lifestyle-related factors Leisure activities No 103(55,8) 119(57,2) 0,218 Yes Sport 51(27,6) 64(30,7) Music 13(7) 11(5,3) Dance 4(2,2) 6(2,9) Drawing 11(5,3) 5(2,4) Other - 1(0,53) *: p> 0.05 IQR: Interquartile range. ATCD: Antecedents. 5. Mental distress in adolescent victims of cyberbullying Among adolescents victimized by cyberbullying, 53.6% had depression, 51.6% had anxiety symptoms, and 37.1% had a pathological level of stress according to the DASS 21 scale. Figure 1 illustrates the level of each negative emotional state: depression, anxiety and stress. Thus, 41.3% reported moderate to severe depressive symptoms; 47.8% had moderate to severe anxiety levels; and 29.5% had moderate to severe stress levels. Cyberbullying was strongly correlated with depression (p<0.0001), anxiety (p=0.00), and stress (p=0.00) (tableV) Table V: Association between Cyberbullying and mental distress (N= 396) Cyberbullying p Victims % Not victims % Depression Yes 62,7 37,3 0,001 No 36,2 63,8 Anxiety Yes 65,7 34,3 0,000 No 36,2 63,8 Stress Yes 68,1 31,9 0,001 No 38 62 Discussion Cyberbullying, linked to mental health disturbances in youth, was explored in our study to ascertain its prevalence among high school adolescents and to outline the characteristics and psychological states of the victims. In our sample of 396 enrolled adolescents, the prevalence of cyberbullying victims was 47%, with 29.1% reporting witnessing such incidents. A comparison with two Tunisian studies from 2019 ( 4 ) and 2018 ( 5 ) revealed prevalence rates of 34.4% and 22.2%, respectively, among middle school students. The rise in prevalence over the years might be associated with increased smartphone use among the youth and the impact of the COVID-19 pandemic. Internationally, a 2022 study in Saudi Arabia reported a prevalence of 35.3% for cyberbullying victims ( 10 ), while a 2016 study involving 3178 Arab students indicated a prevalence of 14% ( 11 ). A 2020 literature review estimated global cyberbullying prevalence between 15% and 35% ( 12 ). A meta-analysis in the European Union, published in 2022, showed a range from 13.0–53.1% ( 13 ). Global prevalence, spanning from 10–50%, is primarily observed in Western populations. Despite advancements in cyberbullying research, assessing it remains challenging due to diverse forms and a lack of standardized tools, especially in Eastern countries, leading to varying prevalence figures due to methodological differences. 1. Characteristics of Cyberbullying Victims : In our study, although not statistically significant (p = 0.349), we observed a predominance of female victims (106 girls/79 boys). This aligns with previous findings indicating that girls tend to report cyberbullying victimization more frequently than boys ( 14 ). The gender discrepancy is partially attributed to variations in internet usage patterns, with adolescent girls preferring social media for their relationships, potentially increasing their exposure to relational aggression ( 15 ). Additionally, underreporting of cyberbullying incidents among boys may contribute to a lower observed prevalence( 16 ). These results emphasize the need for gender-specific preventive interventions for adolescents. No statistically significant correlation between the age of adolescents and cyberbullying was found in our study, aligning with divergent findings in previous research ( 17 ). Some studies reported no association between age and cyberbullying( 18 ), while others noted interactions between age and gender in the context of email harassment and instant messaging use. Younger boys tended to perceive email harassment as more severe than girls of the same age, with this gap diminishing as they grew older. Certain studies indicated that cyberbullying victimization peaks in early adolescence ( 19 ), while others showed a positive correlation between age and cyberbullying among students aged 10 to 15 years( 20 ), suggesting a concentration of cases during middle school. The majority of victims in our sample lived in urban areas (90.3%), and a statistically significant association between cyberbullying and urban residency was identified (p = 0.017). Various studies support this trend, indicating that children in urban areas are more susceptible to cyberbullying compared to their counterparts in rural or suburban areas ( 4 , 17 ).. Factors contributing to this disparity include insecurity within urban communities, socio-economic differences, and higher prevalence of internet use in urban settings. Cyberbullying correlates significantly with relational issues involving both parents (p = 0.001) and siblings (p = 0.002). These findings align with prior research( 21 ) demonstrating the connection between family dysfunction and adolescents' engagement in cyberbullying. Adolescents experiencing conflict with their parents may be more susceptible to peer bullying or adopt intimidating behaviors. Limited social skills and inappropriate learned strategies can expose them to problematic relationships ( 22 ). Sibling relationships also play a role in cyberbullying, where strained relationships may weaken parental supervision( 23 ). Conversely, a supportive sibling relationship can provide protection against cyberbullying, with older siblings, more familiar with the cyber space, sharing experiences and better safeguarding their younger siblings ( 24 ). In our sample, significant associations were found between cyberbullying and both poor academic performance (p = 0.009) and behavioral problems in the school environment (p = 0.000). This aligns with previous research indicating that cyberbullying has a detrimental impact on adolescents' academic performance, contributing to absenteeism, school aversion, and lower academic achievement ( 25 ). The relationship between cyberbullying and school engagement can be bidirectional, with students experiencing poor outcomes being more vulnerable, and victims of cyberbullying potentially losing interest in education. 1. Mental distress in adolescent victims of cyberbullying : In the current study, the prevalence of depression, anxiety, and stress among adolescents victimized by cyberbullying was 53.1%, 51.6%, and 37.1%, respectively. Additionally, 41.3% reported moderate to severe depressive symptoms, 47.8% had moderate to severe anxiety levels, and 29.5% reported moderate to severe stress levels. Cyberbullying was strongly correlated with depression (p < 0.0001), anxiety (p = 0.00), and stress (p = 0.00). Our research confirmed that cyberbullying was associated with high levels of depression, anxiety, and stress in adolescents, consistent with other studies ( 26 ). The literature results highlight a significant correlation between cyber victimization and an increased predisposition to symptoms of depression, anxiety, and stress ( 26 – 28 ) A meta-analysis published in January 2022 ( 29 ), including 156 studies, concluded a strong association between the experience of cyberbullying and mental distress. This form of bullying can harm the mental health of adolescents, amplifying distress due to the negative self-perception induced by bullying ( 30 ). Most studies used cross-sectional designs, with very few examining the bidirectional relationship between cyber victimization and depressive symptoms ( 31 ). Cyber victimization leads to the development of depressive symptoms, and depressive symptoms, in turn, increase the risk of cyber victimization. Recently, two longitudinal studies indicate a significant bidirectional relationship between depressive symptoms and cyber victimization in adolescents and students ( 32 ). Another longitudinal study involving 559 adolescents in the United States showed a bidirectional relationship between cyber victimization and anxiety, but not for depressive symptoms ( 33 ).Several studies have put forward the idea that depression, anxiety, and problematic behaviors can act as both precursors and consequences of cyberbullying( 34 ). Depressed youth are more likely to be victims of cyberbullying when they use the internet more frequently to communicate with strangers ( 35 ). Depressed adolescents are less likely to defend themselves, increasing the likelihood of being bullied by harassers ( 36 ). Therefore, depressive symptoms may significantly predict cyber victimization. From the perspective of the vulnerability-stress model for depression ( 37 ),victimization, such as cyber victimization, is considered a significant stress factor in adolescents' lives, increasing the risk of developing depressive symptoms. In other words, adolescents' victimization experiences can activate and reinforce their negative cognitive patterns, thereby increasing the risk of depressive symptoms ( 38 ). Another study indicated that depression and anxiety provide fertile ground for fostering electronic violence. According to Ronis and Slaunwhite, involvement in cyberbullying can lead to insecurity, anxiety, and a high degree of depression ( 39 ). Based on previous research ( 32 ), a significant relationship has been observed between students' anxiety levels and cyberbullying. In summary, the findings indicate that students that are more anxious tend to engage more in cyberbullying, while those with lower anxiety levels are less likely to be victims of cyberbullying. Therefore, anxiety emerges as a key factor in understanding how these students behave online. Cyberbullying, encompassing social exclusion and verbal harassment, significantly influences emotional responses, stress, and coping strategies ( 40 ). Victims exhibit negative emotions, experience heightened stress, especially due to social exclusion, and adapt their coping mechanisms, underscoring the close connection between cyberbullying and psychosocial stress. LIMITATIONS OF THE STUDY While this research has shed light on cyberbullying among adolescents, a few limitations deserve mention. Firstly, the limited size of the sample compared to all high school students could hinder generalizing the results to the entire high school population in Tunisia. Additionally, although the cyberbullying scale was used as a tool, its scientific validation specifically in Arabic and in the Tunisian context needs further exploration. This scale does not cover all the complex aspects of cyberbullying, such as the methods used and the positions of adolescents in online interactions. By limiting itself to a quantitative assessment, important nuances of adolescents' experiences may have been overlooked. To address these gaps, qualitative interviews with adolescents could enrich our understanding by providing a more in-depth insight into their lived experiences and perceptions. Conclusion Social media has transformed the interactions of young people, but cyberbullying is emerging as a threat to mental health. Our study aimed to identify factors associated with cyberbullying among adolescents in Sfax and examine its connection to mental distress. Our study highlights the extent of cyberbullying, its risks, and the need for multidimensional prevention involving individuals, families, schools, and communities Declarations Availability of data and materials: Data sharing does not apply as no datasets were generated or analysed during the current study. Human Ethics and Consent to Participate: This study was duly authorized by both regional education authorities, Sfax 1 and Sfax 2, under the auspices of the Ministry of National Education of Tunisia. The study complies with the Declaration of Helsinki. All participants provided their written informed consent to participate in the study. Funding: This research received no external funding Competing interests :The authors declare that they have no competing interests. Author Contribution Ben Touhemi D and Chabbeen M designed the study and drafted the manuscript. Khemakhem K and Chiha K helped to edit the manuscript and performed statistical analyses. Ayadi H and Moalla Y supervised the study and edited the manuscript. All authors have read and approved the final version of the manuscript. References Gozlan A. Le héros éphémère sur la scène facebookienne. Topique. 2014;126(1):51–63. Frédérique PL, Mazoyer AV, Marjorie R. Enjeux psychiques du virtuel à l’adolescence. Bull Psychol. 2014;Num–ro 534(6):467–85. Actuel/virtuel. Introduction a une problématique architecturaleDNArchi [Internet]. 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Early maladaptive schemas as moderators of the association between bullying victimization and depressive symptoms in adolescents. https://psycnet.apa.org/record/2017-47205-001 . Ronis S, Slaunwhite A. Gender and Geographic Predictors of Cyberbullying Victimization, Perpetration, and Coping Modalities Among Youth. Can J Sch Psychol. 2019;34(1):3–21. Alhujailli A, Karwowski W, Wan TTH, Hancock P. Affective and Stress Consequences of Cyberbullying. Symmetry. 2020;12(9):1536. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4148550","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":284306148,"identity":"abdb3733-50e1-43f1-8efb-0c6391d49ac4","order_by":0,"name":"Donia Ben Touhemi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYDCCAzAEBMxAzMMPYiUUEKOFDapFsgGkxQC/FgZkLQwGYBE8WviO9x488IPhjpy5fPMx6YKKbTLG51cnfnhgwCDPL3YAqxbJM+cSDvYwPDO2bGNLk55x5jaP2Y23myWADjOcOTsBqxaDGzkGB3gYDiduOMZjJs3bBtJydgNIS4LBbdxaDv5hOFwP0fLvNo/xjLObfxDSchhoS4IBWEvDbR4D/t5teG2RPHPG4LCMwTPDDcfSkq15jt3mkbjBu80iwUACp1/4jvcYf3xTcUfe4PDhg7d5am7b8/ef3XzzR4WNPL80di1Q5yFzJMAqJfAoxwD8B0hRPQpGwSgYBSMAAAA0/2VSE9eqNAAAAABJRU5ErkJggg==","orcid":"","institution":"Hospital University Hedi CHEKER Sfax","correspondingAuthor":true,"prefix":"","firstName":"Donia","middleName":"Ben","lastName":"Touhemi","suffix":""},{"id":284306149,"identity":"14822b16-22fb-4d2c-979e-cc62d6de0d56","order_by":1,"name":"Chaabane Maryam","email":"","orcid":"","institution":"Hospital University Hedi CHEKER Sfax","correspondingAuthor":false,"prefix":"","firstName":"Chaabane","middleName":"","lastName":"Maryam","suffix":""},{"id":284306150,"identity":"48b4b4e1-9cbe-4564-80b4-48f99b291fa7","order_by":2,"name":"Khemakhem Khaoula","email":"","orcid":"","institution":"Hospital University Hedi CHEKER Sfax","correspondingAuthor":false,"prefix":"","firstName":"Khemakhem","middleName":"","lastName":"Khaoula","suffix":""},{"id":284306151,"identity":"dbf677f6-749f-45c1-ad2e-9f3375c2ca5d","order_by":3,"name":"Chiha khadija","email":"","orcid":"","institution":"Hospital University Hedi CHEKER Sfax","correspondingAuthor":false,"prefix":"","firstName":"Chiha","middleName":"","lastName":"khadija","suffix":""},{"id":284306152,"identity":"b72caefd-a2a5-4ed8-8557-ca4fc67a57f6","order_by":4,"name":"Ayadi Hela","email":"","orcid":"","institution":"Hospital University Hedi CHEKER Sfax","correspondingAuthor":false,"prefix":"","firstName":"Ayadi","middleName":"","lastName":"Hela","suffix":""},{"id":284306153,"identity":"b1dcdf40-d2f9-4326-bf5a-75bc5a2cae13","order_by":5,"name":"Moalla Yousr","email":"","orcid":"","institution":"Hospital University Hedi CHEKER Sfax","correspondingAuthor":false,"prefix":"","firstName":"Moalla","middleName":"","lastName":"Yousr","suffix":""}],"badges":[],"createdAt":"2024-03-22 09:18:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4148550/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4148550/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53756388,"identity":"b3c72505-9480-4b5f-b5cf-3c745984ee77","added_by":"auto","created_at":"2024-03-29 19:02:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18873,"visible":true,"origin":"","legend":"\u003cp\u003eMental distress levels among adolescents (N= 396)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4148550/v1/5a9144615f5c5398877c59c0.png"},{"id":54180515,"identity":"86e61090-54fe-45be-8b41-d5d9d693a161","added_by":"auto","created_at":"2024-04-05 16:30:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":497178,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4148550/v1/46c53311-8dbc-4c36-9bc8-17a3494c21c3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cyberbullying and mental distress among adolescents in secondary school: Tunisian cross sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eYoung people are now closely connected to social networks and their smartphones. This fusion with technology has given rise to the concept of 'virtualescence' (Gozlan) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), which describes adolescence in the digital age., where online spaces are used to address the psychological challenges of adolescence (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Social media stands out for its ability to instantly share online content with thousands of people within seconds, thereby reducing distances and privacy boundaries. As a result, adolescents are increasingly involved in interactions related to cyberbullying (CB): a new form of harassment through electronic media. CB encompasses acts of intimidating, threatening, or coercing individuals online through social media, emails, text messages, blog posts, or any other digital or electronic communication method. This category of harassment has become a global phenomenon, affecting both adolescents and children. It is rapidly expanding independently of the country development level, with a prevalence ranging from 6\u0026ndash;46%.\"\u003c/p\u003e \u003cp\u003eIt is important to note that despite the terms 'virtual' and 'cyber,' this violence has real consequences, affecting individuals with concrete emotions and social connections (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Its psychological consequences appear to be stronger and more enduring than traditional bullying. It can cause severe psychological disorders such as depression, withdrawal/isolation, loss of self-esteem, and even suicidal thoughts and suicide attempts.\u003c/p\u003e \u003cp\u003eIn Tunisia, few studies have been conducted to assess the prevalence of cyberbullying among adolescents. A study by Bassem Abida in 2019 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) at Sfax, Tunisia revealed a rate of 34.4%, and another study in 2018 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) in Sousse found a prevalence of 22.2% among 1111 middle school students. This urgency is further underscored by a study involving samples of adolescents from both Tunisia and Lebanon, which has highlighted a significant connection between cyberbullying and mental distress. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIt is in this context that we conducted our study, which aimed to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIdentify the individual and environmental characteristics of adolescents victims of cyberbullying\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAssess the psychological state of cyberbullying victims\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Methodology ","content":"\u003cp\u003eThis study was conducted during the month of February 2022. It took place in public secondary educational institutions in the Sfax region, Tunisia. A cross-sectional, descriptive, and analytical method was undertaken.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Study population :\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe target population consisted of students enrolled in public secondary educational institutions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Study Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to the survey, we obtained the approval of the regional education authorities \u0026ldquo;Sfax 1\u0026rdquo; and \u0026ldquo;Sfax 2\u0026rdquo;. Subsequently, we randomly selected 3 secondary educational institutions under each of these authorities. Within each institution, we also randomly selected classes representing various grade levels.\u003c/p\u003e\n\u003cp\u003eThe adolescents answered the questionnaire in a self-administered manner, following informed consent. Two child and adolescent psychiatrists were present during this stage to emphasize the anonymous nature of the survey and, if necessary, to clarify or comment on the questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Population\u0026nbsp;\u003c/strong\u003eAll adolescents enrolled in secondary education institutions in the Sfax region, Tunisia, were eligible for our study. The only exclusion criteria were refusal to participate in the study or documented psychiatric history.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e4.1 Information Sheet:\u003c/p\u003e\n\u003cp\u003eThe questionnaire was organized into several sections: sociodemographic characteristics, family environment, education, and leisure activities of adolescents.\u003c/p\u003e\n\u003cp\u003e4.2 Psychometric Tools\u003c/p\u003e\n\u003cp\u003e4..3.1\u0026nbsp;\u0026nbsp;\u003cem\u003eCyber-Harassement Student Survey\u003c/em\u003e : \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cbr\u003e\u0026nbsp;Beran and Li\u0026apos;s 15-item Cyber-Harassment Student Survey was employed to evaluate cyberbullying (7). The survey included questions that focused on the frequency of students\u0026apos; exposure to, personal experiences with, and involvement in cyberbullying. Each question was treated independently, and responses were subjected to descriptive analysis. Participants rated their responses on a Likert scale, ranging from \u0026quot;never\u0026quot; to \u0026quot;almost every day,\u0026quot; with higher scores indicating a higher level of cyberbullying experience. Since these scales were not initially available in Arabic during the study, we utilized a version translated into Arabic by the authors, which was subsequently reviewed and corrected by an Arabic teacher.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.2.1\u0026nbsp;\u003c/em\u003eStress Depression, Anxiety, Stress Scale (DASS21) :\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis scale, developed by Lovibond et al., 1995\u0026nbsp;(8), assesses three negative emotional states (Depression, Anxiety, and Stress). The depression scale assesses dysphoria, hopelessness, lack of interest/engagement, devaluation of life, self-deprecation, anhedonia, and inertia. The anxiety scale assesses autonomic arousal, situational anxiety, skeletal muscle effects, and experiences of anxiety. The stress scale assesses difficulty in relaxing, nervous arousal, and mood changes (distress, restlessness, irritability, hyperactivity, and impatience). These items were rated on a 4-point Likert scale, ranging from 1 (did not apply to me at all) to 3 (applied to me very much or most of the time). Total scores for depression, anxiety, and stress were calculated by aggregating their respective points. Each total was then doubled and categorized as \u0026apos;normal,\u0026apos; \u0026apos;mild,\u0026apos; \u0026apos;moderate,\u0026apos; \u0026apos;severe,\u0026apos; or \u0026apos;extremely severe.\u0026apos; The validated Arabic version\u0026nbsp;(9)\u0026nbsp;was used in our study.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Statistical analysis:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data entry and analysis were performed using the Statistical Package for Social Sciences (SPSS) software in its 26th version.\u0026nbsp;The statistical study consisted of two parts:\u003c/p\u003e\n\u003cp\u003e5.1 Descriptive Study:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Quantitative variables were described using means (M), medians, standard deviation (SD), and extreme values. For these variables, we checked the normality of the distribution using the Kolmogorov-Smirnov test and the Shapiro-Wilk test. Qualitative variables were described using absolute frequencies and relative frequencies (percentages).\u003c/p\u003e\n\u003cp\u003e5.2 Analytical Study:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;For the analytical study, We used:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eThe chi-square test (\u0026chi;2) to compare two qualitative variables or Fisher\u0026apos;s exact test when one or more of the theoretical cell frequencies in the contingency table are less than five.\u003c/li\u003e\n \u003cli\u003eIndependent samples t-test to compare means when dealing with one dependent quantitative variable and another independent qualitative variable.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e1. Response Rate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix hundred questionnaire samples were distributed across six schools, and 396 forms were collected. The response rate was 66%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Characteristics of Participants:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe average age of recruited adolescents was 16.69 years, with a predominance of females, and more than half were enrolled in the first year of secondary school. The main descriptive results of the sample are presented in Table I.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable I:\u0026nbsp;\u003c/strong\u003eDescriptive characteristics of recruited adolescents.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.668711656441715%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Data\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.331288343558285%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.668711656441715%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMean age\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.331288343558285%\" valign=\"top\"\u003e\n \u003cp\u003e16.69 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.668711656441715%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSex ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.331288343558285%\" valign=\"top\"\u003e\n \u003cp\u003e0,827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.668711656441715%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.331288343558285%\" valign=\"top\"\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.04147465437788%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eSchool level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.56221198156682%\" valign=\"top\"\u003e\n \u003cp\u003e1st year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.3963133640553%\" valign=\"top\"\u003e\n \u003cp\u003e114(51,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.91017964071856%\" valign=\"top\"\u003e\n \u003cp\u003e2nd year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.08982035928144%\" valign=\"top\"\u003e\n \u003cp\u003e89(40,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.91017964071856%\" valign=\"top\"\u003e\n \u003cp\u003e3rd year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.08982035928144%\" valign=\"top\"\u003e\n \u003cp\u003e13(5,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.91017964071856%\" valign=\"top\"\u003e\n \u003cp\u003e4th year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.08982035928144%\" valign=\"top\"\u003e\n \u003cp\u003e4(1,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Cyberbullying in schools:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, 185 (46.7%) of the participants reported being victims of cyberbullying, and 29.7% of adolescents reported witnessing an act of cyberbullying. Among the cyber victims, 9.1%, in turn, used new technologies to aggress their peers, thus becoming cyber aggressors. Among the victimized adolescents, 58.4% (n = 108) were attacked online once or twice. (Table II).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable II:\u0026nbsp;\u003c/strong\u003ePrevalence and characteristics of cyberbullying: (N= 396)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.061349693251536%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.938650306748464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.061349693251536%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVictims of cyberbullying\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.938650306748464%\" valign=\"top\"\u003e\n \u003cp\u003e185 (46,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.061349693251536%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWitnesses of cyberbullying\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.938650306748464%\" valign=\"top\"\u003e\n \u003cp\u003e117 (29,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.061349693251536%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCyber aggressor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.938650306748464%\" valign=\"top\"\u003e\n \u003cp\u003e36 (9,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.779141104294478%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of cyberbullying among victims\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N\u0026nbsp;= 185)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.282208588957054%\" valign=\"top\"\u003e\n \u003cp\u003eOnce or twice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.938650306748464%\" valign=\"top\"\u003e\n \u003cp\u003e108 (58,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.549019607843135%\" valign=\"top\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.450980392156865%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;61 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.549019607843135%\" valign=\"top\"\u003e\n \u003cp\u003eSeveral times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.450980392156865%\" valign=\"top\"\u003e\n \u003cp\u003e14 (7,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.549019607843135%\" valign=\"top\"\u003e\n \u003cp\u003eEvery day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.450980392156865%\" valign=\"top\"\u003e\n \u003cp\u003e2 (1,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Individual and environmental characteristics of adolescent victims of cyberbullying:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe individual and environmental characteristics of adolescent victims of cyberbullying are presented in Table III.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable III:\u0026nbsp;\u003c/strong\u003eIndividual, family and school/social factors associated with Cyberbullying.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"60.60606060606061%\" colspan=\"3\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.515151515151516%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCyberbullying\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.878787878787879%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.42857142857143%\" valign=\"top\"\u003e\n \u003cp\u003eVictims\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.57142857142857%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNon-victims\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocio-demographic factors :\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"60.60606060606061%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.575757575757576%\" valign=\"top\"\u003e\n \u003cp\u003e17 IQR [16 - 17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.93939393939394%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e17 IQR [16 - 17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.878787878787879%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e106(57,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e110(52,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e79(42,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e98(47,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonal history\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedical Surgical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5(2,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e4(98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e180(97,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e204(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonal psychiatric history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e185(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e208(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeographic origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eurban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e167(90,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e200(96,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003erural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e18(9,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e8(3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel Socio-economic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003elow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e62(33,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e74(35,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMedium to high\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e123(66,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e134(64,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily environment factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFather\u0026apos;s education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e33(17,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e25(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSecondary/ university\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e152(82,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e183(88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFather\u0026apos;s activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003einactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5(2,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e2(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e180(97,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e206(99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026apos;s education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e31(16,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e29(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,439\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSecondary/ university\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e154(83,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e179(86)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActivit\u0026eacute; de m\u0026egrave;re\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e90(48,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e98(47,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,761\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e95(51,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e110(52,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily medical and surgical history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e14(7,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e10(4,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,254\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e171(92,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e198(95,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily psychiatric history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5(2,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e2(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e180(97,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e206(99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents\u0026apos; marital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eUnited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e168(90,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e194(93,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,367\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSeparated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e17(9,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e14(6,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents\u0026apos; marital conflicts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e21(11,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e17(8,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,287\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e164(88,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e191(91,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship problems with parents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e165(89,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e204(98,07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.846153846153847%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.025641025641026%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2(1,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e3(1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eVerbal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8(4,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eNeglect \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5(2,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e1(0,53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eLack of communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5(2,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship problems with siblings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e164(88,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e203(97,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e0,002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.846153846153847%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.025641025641026%\" valign=\"top\"\u003e\n \u003cp\u003ePhysical\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2(1,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e1(0,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eVerbal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e9(4,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e2(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eRivality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5(2,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e2(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eLack of communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5(2,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool-related factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool results\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e35(18,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e63(30,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePoor to average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e150(81,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e145(69,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcademic repetition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e46(24,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e38(18,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e139(75,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e170(81,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool-related problems\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e158(85,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e200(96,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e0,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.846153846153847%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.025641025641026%\" valign=\"top\"\u003e\n \u003cp\u003e11(5,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e11(5,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e2(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003e4(2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4(2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e3(1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003e4(2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4(2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003e8(4,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8(4,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e3(1,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship problems with peers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e10(5,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e6(2,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,207\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.87179487179487%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e175(94,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e202(97,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLifestyle-related factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeisure activities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.37518910741301%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708018154311649%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e103(55,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\" valign=\"top\"\u003e\n \u003cp\u003e119(57,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e0,218\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.846153846153847%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.025641025641026%\" valign=\"top\"\u003e\n \u003cp\u003eSport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e51(27,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.58974358974359%\" valign=\"top\"\u003e\n \u003cp\u003e64(30,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eMusic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e13(7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e11(5,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eDance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4(2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e6(2,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eDrawing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e11(5,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e5(2,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.74074074074074%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.282828282828284%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.976430976430976%\" valign=\"top\"\u003e\n \u003cp\u003e1(0,53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.139183055975796%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.069591527987898%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.305597579425115%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.556732223903177%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.15128593040847202%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.918305597579424%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.85930408472012%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*: p\u0026gt; 0.05 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; IQR: Interquartile range. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;ATCD: Antecedents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Mental distress in adolescent victims of cyberbullying\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong adolescents victimized by cyberbullying, 53.6% had depression, 51.6% had anxiety symptoms, and 37.1% had a pathological level of stress according to the DASS 21 scale.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 1 illustrates the level of each negative emotional state: depression, anxiety and stress. Thus, 41.3% reported moderate to severe depressive symptoms; 47.8% had moderate to severe anxiety levels; and 29.5% had moderate to severe stress levels.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCyberbullying was strongly correlated with depression (p\u0026lt;0.0001), anxiety (p=0.00), and stress (p=0.00) (tableV)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable V:\u0026nbsp;\u003c/strong\u003eAssociation between Cyberbullying and mental distress (N= 396)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.644951140065146%\" colspan=\"2\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"51.302931596091206%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eCyberbullying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.052117263843648%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.84126984126984%\" valign=\"top\"\u003e\n \u003cp\u003eVictims\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.15873015873016%\" valign=\"top\"\u003e\n \u003cp\u003eNot victims\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.960912052117264%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.684039087947884%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570032573289904%\" valign=\"top\"\u003e\n \u003cp\u003e62,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.732899022801302%\" valign=\"top\"\u003e\n \u003cp\u003e37,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.052117263843648%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.733031674208146%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.52036199095023%\" valign=\"top\"\u003e\n \u003cp\u003e36,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.74660633484163%\" valign=\"top\"\u003e\n \u003cp\u003e63,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.960912052117264%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.684039087947884%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570032573289904%\" valign=\"top\"\u003e\n \u003cp\u003e65,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.732899022801302%\" valign=\"top\"\u003e\n \u003cp\u003e34,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.052117263843648%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.733031674208146%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.52036199095023%\" valign=\"top\"\u003e\n \u003cp\u003e36,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.74660633484163%\" valign=\"top\"\u003e\n \u003cp\u003e63,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.960912052117264%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.684039087947884%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.570032573289904%\" valign=\"top\"\u003e\n \u003cp\u003e68,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.732899022801302%\" valign=\"top\"\u003e\n \u003cp\u003e31,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.052117263843648%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.733031674208146%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.52036199095023%\" valign=\"top\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.74660633484163%\" valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCyberbullying, linked to mental health disturbances in youth, was explored in our study to ascertain its prevalence among high school adolescents and to outline the characteristics and psychological states of the victims.\u003c/p\u003e \u003cp\u003eIn our sample of 396 enrolled adolescents, the prevalence of cyberbullying victims was 47%, with 29.1% reporting witnessing such incidents. A comparison with two Tunisian studies from 2019 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and 2018 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) revealed prevalence rates of 34.4% and 22.2%, respectively, among middle school students. The rise in prevalence over the years might be associated with increased smartphone use among the youth and the impact of the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eInternationally, a 2022 study in Saudi Arabia reported a prevalence of 35.3% for cyberbullying victims (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), while a 2016 study involving 3178 Arab students indicated a prevalence of 14% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). A 2020 literature review estimated global cyberbullying prevalence between 15% and 35% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A meta-analysis in the European Union, published in 2022, showed a range from 13.0\u0026ndash;53.1% (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Global prevalence, spanning from 10\u0026ndash;50%, is primarily observed in Western populations. Despite advancements in cyberbullying research, assessing it remains challenging due to diverse forms and a lack of standardized tools, especially in Eastern countries, leading to varying prevalence figures due to methodological differences.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e1. Characteristics of Cyberbullying Victims :\u003c/h2\u003e \u003cp\u003eIn our study, although not statistically significant (p\u0026thinsp;=\u0026thinsp;0.349), we observed a predominance of female victims (106 girls/79 boys). This aligns with previous findings indicating that girls tend to report cyberbullying victimization more frequently than boys (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The gender discrepancy is partially attributed to variations in internet usage patterns, with adolescent girls preferring social media for their relationships, potentially increasing their exposure to relational aggression (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Additionally, underreporting of cyberbullying incidents among boys may contribute to a lower observed prevalence(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These results emphasize the need for gender-specific preventive interventions for adolescents.\u003c/p\u003e \u003cp\u003eNo statistically significant correlation between the age of adolescents and cyberbullying was found in our study, aligning with divergent findings in previous research (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Some studies reported no association between age and cyberbullying(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), while others noted interactions between age and gender in the context of email harassment and instant messaging use. Younger boys tended to perceive email harassment as more severe than girls of the same age, with this gap diminishing as they grew older. Certain studies indicated that cyberbullying victimization peaks in early adolescence (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), while others showed a positive correlation between age and cyberbullying among students aged 10 to 15 years(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), suggesting a concentration of cases during middle school.\u003c/p\u003e \u003cp\u003eThe majority of victims in our sample lived in urban areas (90.3%), and a statistically significant association between cyberbullying and urban residency was identified (p\u0026thinsp;=\u0026thinsp;0.017). Various studies support this trend, indicating that children in urban areas are more susceptible to cyberbullying compared to their counterparts in rural or suburban areas (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).. Factors contributing to this disparity include insecurity within urban communities, socio-economic differences, and higher prevalence of internet use in urban settings.\u003c/p\u003e \u003cp\u003eCyberbullying correlates significantly with relational issues involving both parents (p\u0026thinsp;=\u0026thinsp;0.001) and siblings (p\u0026thinsp;=\u0026thinsp;0.002). These findings align with prior research(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) demonstrating the connection between family dysfunction and adolescents' engagement in cyberbullying. Adolescents experiencing conflict with their parents may be more susceptible to peer bullying or adopt intimidating behaviors. Limited social skills and inappropriate learned strategies can expose them to problematic relationships (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Sibling relationships also play a role in cyberbullying, where strained relationships may weaken parental supervision(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Conversely, a supportive sibling relationship can provide protection against cyberbullying, with older siblings, more familiar with the cyber space, sharing experiences and better safeguarding their younger siblings (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our sample, significant associations were found between cyberbullying and both poor academic performance (p\u0026thinsp;=\u0026thinsp;0.009) and behavioral problems in the school environment (p\u0026thinsp;=\u0026thinsp;0.000). This aligns with previous research indicating that cyberbullying has a detrimental impact on adolescents' academic performance, contributing to absenteeism, school aversion, and lower academic achievement (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The relationship between cyberbullying and school engagement can be bidirectional, with students experiencing poor outcomes being more vulnerable, and victims of cyberbullying potentially losing interest in education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e1. Mental distress in adolescent victims of cyberbullying :\u003c/h2\u003e \u003cp\u003eIn the current study, the prevalence of depression, anxiety, and stress among adolescents victimized by cyberbullying was 53.1%, 51.6%, and 37.1%, respectively. Additionally, 41.3% reported moderate to severe depressive symptoms, 47.8% had moderate to severe anxiety levels, and 29.5% reported moderate to severe stress levels.\u003c/p\u003e \u003cp\u003eCyberbullying was strongly correlated with depression (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), anxiety (p\u0026thinsp;=\u0026thinsp;0.00), and stress (p\u0026thinsp;=\u0026thinsp;0.00). Our research confirmed that cyberbullying was associated with high levels of depression, anxiety, and stress in adolescents, consistent with other studies (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe literature results highlight a significant correlation between cyber victimization and an increased predisposition to symptoms of depression, anxiety, and stress (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA meta-analysis published in January 2022 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), including 156 studies, concluded a strong association between the experience of cyberbullying and mental distress. This form of bullying can harm the mental health of adolescents, amplifying distress due to the negative self-perception induced by bullying (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Most studies used cross-sectional designs, with very few examining the bidirectional relationship between cyber victimization and depressive symptoms (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Cyber victimization leads to the development of depressive symptoms, and depressive symptoms, in turn, increase the risk of cyber victimization. Recently, two longitudinal studies indicate a significant bidirectional relationship between depressive symptoms and cyber victimization in adolescents and students (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Another longitudinal study involving 559 adolescents in the United States showed a bidirectional relationship between cyber victimization and anxiety, but not for depressive symptoms (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).Several studies have put forward the idea that depression, anxiety, and problematic behaviors can act as both precursors and consequences of cyberbullying(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDepressed youth are more likely to be victims of cyberbullying when they use the internet more frequently to communicate with strangers (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Depressed adolescents are less likely to defend themselves, increasing the likelihood of being bullied by harassers (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Therefore, depressive symptoms may significantly predict cyber victimization.\u003c/p\u003e \u003cp\u003eFrom the perspective of the vulnerability-stress model for depression (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e),victimization, such as cyber victimization, is considered a significant stress factor in adolescents' lives, increasing the risk of developing depressive symptoms. In other words, adolescents' victimization experiences can activate and reinforce their negative cognitive patterns, thereby increasing the risk of depressive symptoms (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother study indicated that depression and anxiety provide fertile ground for fostering electronic violence. According to Ronis and Slaunwhite, involvement in cyberbullying can lead to insecurity, anxiety, and a high degree of depression (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBased on previous research (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), a significant relationship has been observed between students' anxiety levels and cyberbullying. In summary, the findings indicate that students that are more anxious tend to engage more in cyberbullying, while those with lower anxiety levels are less likely to be victims of cyberbullying. Therefore, anxiety emerges as a key factor in understanding how these students behave online.\u003c/p\u003e \u003cp\u003eCyberbullying, encompassing social exclusion and verbal harassment, significantly influences emotional responses, stress, and coping strategies (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Victims exhibit negative emotions, experience heightened stress, especially due to social exclusion, and adapt their coping mechanisms, underscoring the close connection between cyberbullying and psychosocial stress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS OF THE STUDY\u003c/h2\u003e \u003cp\u003eWhile this research has shed light on cyberbullying among adolescents, a few limitations deserve mention. Firstly, the limited size of the sample compared to all high school students could hinder generalizing the results to the entire high school population in Tunisia. Additionally, although the cyberbullying scale was used as a tool, its scientific validation specifically in Arabic and in the Tunisian context needs further exploration. This scale does not cover all the complex aspects of cyberbullying, such as the methods used and the positions of adolescents in online interactions. By limiting itself to a quantitative assessment, important nuances of adolescents' experiences may have been overlooked. To address these gaps, qualitative interviews with adolescents could enrich our understanding by providing a more in-depth insight into their lived experiences and perceptions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSocial media has transformed the interactions of young people, but cyberbullying is emerging as a threat to mental health. Our study aimed to identify factors associated with cyberbullying among adolescents in Sfax and examine its connection to mental distress. Our study highlights the extent of cyberbullying, its risks, and the need for multidimensional prevention involving individuals, families, schools, and communities\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAvailability of data and materials: \u0026nbsp;Data sharing does not apply as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003eHuman Ethics and Consent to Participate: This study was duly authorized by both regional education authorities, Sfax 1 and Sfax 2, under the auspices of the Ministry of National Education of Tunisia. The study complies with the Declaration of Helsinki. All participants provided their written informed consent to participate in the study.\u003c/p\u003e\n\u003cp\u003eFunding: This research received no external funding\u003c/p\u003e\n\u003cp\u003eCompeting interests :The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBen Touhemi D and Chabbeen M designed the study and drafted the manuscript. Khemakhem K and Chiha K helped to edit the manuscript and performed statistical analyses. Ayadi H and Moalla Y supervised the study and edited the manuscript. All authors have read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGozlan A. Le h\u0026eacute;ros \u0026eacute;ph\u0026eacute;m\u0026egrave;re sur la sc\u0026egrave;ne facebookienne. 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Internet Addiction and Predictors of Cyberbullying and Cybervictimization among Female Nursing University Students: A Cross Sectional Study. Int J Environ Res Public Health. 2023;20(5):4293.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRose CA, Tynes BM. Longitudinal Associations Between Cybervictimization and Mental Health Among U.S. Adolescents. J Adolesc Health Off Publ Soc Adolesc Med. 2015;57(3):305\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlenik-Shemesh D, Heiman T, Eden S. Cyberbullying victimisation in adolescence: Relationships with loneliness and depressive mood. Emot Behav Difficulties. 2012;17(3\u0026ndash;4):361\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao L, Liu J, Yang J, Wang X. Longitudinal Relationships among Cybervictimization, Peer pressure, and Adolescents\u0026rsquo; Depressive Symptoms. J Affect Disord. 2021;286:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodges EVE, Perry DG. Personal and interpersonal antecedents and consequences of victimization by peers. J Pers Soc Psychol. 1999;76(4):677\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHankin B, Abela J. Development of Psychopathology: A Vulnerability-Stress Perspective [Internet]. Thousand Oaks, California; 2005 [cited 2023 Nov 15]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sk.sagepub.com/books/development-of-psychopathology\u003c/span\u003e\u003cspan address=\"https://sk.sagepub.com/books/development-of-psychopathology\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAPA PsycNET [Internet]. [cited 2023 Nov 14]. Early maladaptive schemas as moderators of the association between bullying victimization and depressive symptoms in adolescents. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://psycnet.apa.org/record/2017-47205-001\u003c/span\u003e\u003cspan address=\"https://psycnet.apa.org/record/2017-47205-001\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRonis S, Slaunwhite A. Gender and Geographic Predictors of Cyberbullying Victimization, Perpetration, and Coping Modalities Among Youth. Can J Sch Psychol. 2019;34(1):3\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhujailli A, Karwowski W, Wan TTH, Hancock P. Affective and Stress Consequences of Cyberbullying. Symmetry. 2020;12(9):1536.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"adolescents, cyberbullying, Mental distress, depression, anxiety","lastPublishedDoi":"10.21203/rs.3.rs-4148550/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4148550/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Ours study aimed to describe the characteristics of adolescents who are victims of cyberbullying and to evaluate the psychological state of these victims.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis is a cross-sectional, descriptive, and analytical study conducted with a representative sample of adolescents attending 6 schools in the Sfax region during the month of February 2022. The pre-established form containing socio-demographic and family information was used. Cyberbullying was assessed using the \"Cyber-Harassment Student Survey\". Mental distress was evaluated using the Depression Anxiety Stress Scales (DASS-21), validated in Arabic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Data was collected data from 396 adolescents, of which 54.8% were female. The average age of participants was 16.65 years. \u003cbr\u003e\nCyberbullying was reported by 47% of the surveyed adolescents.\u003c/p\u003e\n\u003cp\u003eFactors associated with cyberbullying in these adolescents included residing in urban areas (p = 0.017), experiencing relational problems with parents (p = 0.001) and siblings (p = 0.002), the presence of behavioral problems in school (p = 0.009), and low academic performance (p = 0.000)\u003c/p\u003e\n\u003cp\u003eAmong cyberbullying victims, 41.3% reported moderate to severe depressive symptoms; 47.8% had moderate to severe anxiety levels, and 29.5% had moderate to severe stress levels. Cyberbullying was strongly correlated with depression (p \u0026lt; 0.0001), anxiety (p = 0.00), and stress (p = 0.00).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe results of this study indicate that cyberbullying is widespread within schools and has negative consequences on the mental health of young individuals. Recognizing this prevalence is essential and calls for a prevention strategy against cyber-related issues.\u003c/p\u003e","manuscriptTitle":"Cyberbullying and mental distress among adolescents in secondary school: Tunisian cross sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-29 19:02:39","doi":"10.21203/rs.3.rs-4148550/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0f8ea985-681c-4ede-b5b1-4be18921fa4b","owner":[],"postedDate":"March 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-05T16:22:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-29 19:02:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4148550","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4148550","identity":"rs-4148550","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}